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NON-HAZARDOUS I. OPOlaI01., ID PIII7880( 2. Page I ol
<br />WASTE MANIFEST
<br />3. Emergency Reseonse Phone 4. Waste Tracking Number r..
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<br />Generator'sairg.and1,406111 ,r f .1 . , . - . Generator's Site Addraz (if difierent than mailing address) 11 r 4,a,,,4%,•;:
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<br />Generator's Phone: ;14490:11.'1139 I
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<br />' Transporter I Company Name LI.S. EPA ID Number P,Z11-o...1illr iliAlriktittl.44 5r#`1l a I *'..:Alaii30.111811i07 ).1? ,
<br />7, Transporter 2 Company Name US. EPA ID Number
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<br />Facility's
<br />8. De‘lialed ckce,!ilY Name and Site Address U.S. EPA ID Number
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<br />Phone; •Vio-1 3-$6:$ I 1'4 / A
<br />.,. 9. Waste Shipping Name and Description 10. Containers 11. Total 12. prIll
<br />Na. type Quantity WI/Vol. I..:
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<br />pesk ling Iripucjicnciand Additionel.leformggen. ,...,„, 4.
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<br />GENERATOR'S/OFFERows CERTIFICATIoTh I hereby declare that the contents of this consignment are telly and accurately desenbed above by the proper shipping name, and are clesoded, packaged. marked and labelediptiearded, and are In ail respects in proper condition for transport according to applicable Ipterational and national 9-avernmenM1 regulations.
<br />Genera esi011orotA Piiple,dfry0ed Name . i . i 1 .. I Signeture ) .`, 1 Month Day Veer
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<br />intemationel Shipments ' o N MI Import to U.S, I ",-,, Export from US..,'. Port of WitlYlexil. ' .
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<br />Transporter SignatUre (lar exports only); Date leaving U.S.:
<br />16. Transporter Achnowledgmoniol Receipt of Materials
<br />Transporter 1 Printedaypedgel,491'...
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<br />Signature • - ' ' Month Day Year
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<br />Transporter 2 Printed!Typed Name Signature . Month Day Year
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<br />17. Discrepancy
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<br />17e. Discrepancy Indication Space ni L_J °gently Type
<br />Manifest
<br />111 Residue Pn aiat Rejection
<br />Reference Number.
<br />III FIllifleleclion
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<br />Alternate Facility (or Goneralor)
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<br />Facility's Phone:
<br />U.S. EPA ID Number
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<br />Signature of Alternate Facifity (or Generator) Month Day Year /1 a z e
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<br />18. Designated Facility Owner or Operator. Certilication of receipt of materials covered by the manifest except as noted in hem 17a
<br />Printed/Typed Name , Signature Month Day Year
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<br />69- LC-0 6 10498 (Rev. 9/09) TRANSPORTER #1
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